World Journal of AIDS, 2012, 2, 117-121 Published Online September 2012 ( 117
HIV Prevention in Papua New Guinea:
Is It Working or Not?
Heather Worth
School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia.
Received April 17th, 2012; revised May 23rd, 2012; accepted June 5th, 2012
Introduction: There is a global call for structural approaches to HIV that go beyond awareness and HIV testing to ap-
proach prevention work via the social and economic drivers of the epidemic. Papua New Guinea is the epicen tre of the
HIV epidemic in the Pacific, with an adult prev alence rate of 0.9%. Since 2004, there has been a concerted response to
HIV, with vastly increased rates of HIV testing and roll-out of an tiretroviral therapy, and considerable funding for HIV
prevention. Objectives: While incidence is slowing there are still a considerable number of new infections each year
and many commentators are worried that HIV prevention is not working in that country. This article aims to critically
examine HIV prevention programs in Papua New Guinea to show whether HIV prevention is effectiveness in reaching
those most vulnerable to infection. Methods: Using data from HIV prevention programs and behavioural surveys this
article will assess how HIV prevention has been carried out and the effectiven ess of those programs. Results: There is
little evidence to ind icate that HIV prevention in Papua New Guinea, particularly among those most at risk of HIV has
been successful. Conclusion: There is a dearth of HIV prevention interventions in Papua New Guinea that go beyond
awareness-raising to deal with the structural drivers of the epidemic.
Keywords: HIV Prevention; Papua New Guinea; Aids-Awarenes s; HIV Drivers; Structural Int erventions
1. Introduction
While Papua New Guinea (PNG) is the wealthiest coun-
try in the Pacific (due mainly to resource extraction) it
has a low HDR index score and is unlikely to meet many
of the Millennium Development Goals by 2015. PNG is
also the epicentre of HIV in the Pacific with an estimated
adult prevalence of 0.9% [1]. HIV spread is heterogene-
ous with the Highlands region and the National Capital
District carrying a higher burden of infection. The data
on HIV incidence in PNG is interesting. Figure 1 indi-
cates that there has been a steep rise in new infections
from 2000, with a sharp drop in 2007 and a slower rise
again in 2009 and 2010 [2]. This signifies a slowing of
the epidemic in PNG although it is too early to tell what
is causing HIV to slow.
In terms of its HIV response, PNG has been successful
in vastly increasing HIV testing—from 1407 in 2004 to
138,581 in 2010. It has also increased access to antiret-
roviral therapy (from 80 people on ART in 2004 to 8522
in 2010). However, there are major supply chain issues,
drug stock-outs, and human resource issues to contend
with as well as financing of ART in the future [3]. ART
may account for what appears to be a slowing of the epi-
demic. There is considerable evidence to indicate that
ART lowers viral load and thus infectiv ity [4-6].
But while PNG has seen a slowing in the numbers of
diagnoses, there are still substantial numbers of people
becoming infected with HIV each year. Thus HIV pre-
vention still remains the most important strategy to re-
spond to HIV in PNG.
There is considerable expenditure on HIV in Papua
New Guinea. AusAID is the dominant d onor for HIV and
AIDS activities in PNG. In 2010, AusAID provided 76
percent of to tal HIV funding of over AUD 53 million [7].
HIV prevention represents 21 per cent of AusAID fund-
ing through government and non-governmental organiza-
tion (NGO) partners since 2006. It is estimated that the
expenditure by AusAID alone on HIV prevention from
2011-2015 will be in the region of $3 billion, [7].
Figure 1. New HIV Diagnoses, Papua New Guinea 1987-
Copyright © 2012 SciRes. WJA
HIV Prevention in Papua New Guinea: Is It Working or Not?
Given large amounts of HIV prevention funding to
Papua New Guinea since the early 200s, is HIV preven-
tion working in PNG?
2. Methods
In order to assess the effectiveness of HIV prevention
programs in PNG, we: 1) undertook an online search of
the two “major” HIV prevention programs that have op-
erated since 2007 in PNG—AusAID’s Tingim Laip pro-
ject which supports people in high risk settings who may
be more vulnerable to HIV and those funded by PNG-
Australia HIV and AIDS Program (PAHAP) to see what
they said they did in terms of HIV prevention; 2) we re-
viewed all published evaluations and assessments of
these programs; and 3) examined them in the light of
available behavioural change data for vulnerable groups
(sex workers and men who hav e sex with men) over time.
The Tingim Laip project, which is the AusAID response
to high risk settings) received AUD10 million from
2007-2010 [8], wh ile PAHAP provided AU$2 0.4 million
in 2009 to sixteen international non-government organi-
zations funded for service delivery, Australian-based
international organizations, as well as PNG faith-based
organizations and local civil society organizations though
this mechanism.
While PAHAP-funded activities and Tingim Laip’s
program do not represent all the HIV prevention activity
in Papua New Guinea, together they represent the over-
whelming majority of activity. Tingim Laip (Phase 1)
was Papua New Guinea’s (PNG) largest community-
based HIV prevention strategy targeting behaviour
change interventions with vulnerable populations in set-
tings where HIV transmission was known or likely to be
high. Key features included: empowering vulnerable com-
munities to develop, implement and monitor their own
responses to HIV; and developing partnerships with gov-
ernment departments, the private sector and civil society
(non-government organizations, community based or-
ganizations and faith-based organizations) in both rural
and urban settings.
3. Results
3.1. HIV Prevention Program Information
We found that data on the PAHAP-funded projects were
extremely hard to access. We could find very little de-
tailed information about most of the programs, including
budget. What we did find indicated that while they often
offered a range of services, much of the work was
small-scale and siloed. It was mainly concentrated (with
a few exceptions) on raising awareness and/or HIV test-
ing. While most claim to be carrying out HIV prevention
activities, this could be as little as encouraging access to
or provision of voluntary counselling and testing for
(VCT) HIV or “increasing HIV awareness”.
Tingim Laip (Phase 1), the largest of all the HIV pre-
vention programs, operated in 36 sites in 11 provinces.
The program was aimed at people and communities, to
build capacity and empower communities at higher risk
of HIV infection by providing them with knowledge,
tools, and ongoing support to design and manage their
own responses to the epidemic. It focused on men,
women, and youth who congregate in “hotspots” where
sex is negotiated: markets, lodgings, and entertainment
sites along major highways and near ports; villages near
mines, other industries, and military posts; and settle-
ments around urban areas. While there was a consider-
able amount of description about the program there was
very little publically-availab le detailed information about
its success.
3.2. Evaluations of Program Effectiveness
For most of the PAHAP-funded organisations there were
no available data on evaluation of their HIV prevention
programs. However, the Papua New Guinea—Australia
HIV and AIDS program: civil society engagement case
study also reports that, “most partners are not contribut-
ing to a comprehensive approach to HIV prevention” p.6
[9]. The PNG Independent Review Group on HIV/
AIDS’s (IRG) review in May 2011 was particularly con-
cerned that HIV prevention among key populations such
as sex workers, men who have sex with men and trans-
gender people (most of which is funded under the PA-
HAP scheme) has not shown any appreciable scale up
since 2010. For example, Poro Sapot’s prevention work
remains small-scale both in terms of numbers of people
reached and geographical coverage. It was also con-
cerned that there was little HIV prevention coverage at
sites where there is a high convergence of risk.
The mid-term evaluation of Tingim Laip in 2007
shows mixed results [10]. The report showed that Tingim
Laip had made inroads into harnessing community en-
ergy and partnerships, and had distributed large numbers
of condoms. However, even though 17.9 million con-
doms were distributed by the National AIDS Council.
Secretariat (NACS) and Provincial AIDS Councils in
2010, up from 8 million in 2007, condom use continues
to be low. The Independent Review Group (2010) [11]
argue that that even in hotels and motels where condom
distribution has been focused, HIV prevention does not
have the intensity and coverage required. While Tingim
Laip’s brief was to focus on “hotspots” of HIV risk, the
Independent Review Group (2011) report states that “A
number of areas of high risk and vulnerability conver-
gence—characterised by mobility and cash flow, late-
night drinking and the availability of sex workers—are
being missed in HIV prevention… [12]. In the context of
Copyright © 2012 SciRes. WJA
HIV Prevention in Papua New Guinea: Is It Working or Not?
Copyright © 2012 SciRes. WJA
upcoming development projects, many more sites of
“high risk convergence” are likely to emerge [12]. Tin-
gim Laip’s mid-term review argued that it had a weak
conceptual framework and did not report outcomes. Thus
it was impossible to assess whether there was any resul-
tant behaviour change.
AusAID’s (draft) Evaluation of the Australian Aid Pro-
gram’s Contribution to the National HIV Response in
Papua New Guinea indicates, “HIV prevention and educa-
tion services have not moved beyond the work done in the
mid-2000s. … Most partners are not using methods that
engage individuals and communities to change to healthier
behaviours” [13]. This, despite the fact that international
behaviour change evidence has demonstrated for several
years that general awareness-raising alone does not change
people’s behaviour [14]. The IRG 2011report and the
ODE review both found that most HIV prevention efforts
lack an understanding of gender and few programs spe-
cifically engage in interventions to address gender-based
violence, sexual coercion and rape, gender roles and rela-
tions, and gender power different ials.
3.3. Evidence of Behavioural Change?
While Papua New Guinea has claimed that it is experi-
encing a generalised epidemic, HIV infection appears to
be considerably higher in sex workers and men who have
sex with men than in the general population. From the
few studies that have collected biological data amongst
sex workers HIV prevalence ranged from 0% (in Goroka
and Kainantu—in 2003) to 19% (in Port Moresby in
2010) (see Tab le 1) [15-17]. I t must be noted that all but
Kelly et al. [18] were convenience samples.
Table 1 indicates that there is no evidence that con-
dom use has increased in sex worker populations. While
there is a plethora of data which measures condom use
with clients; but the methods used and the measurement
of condom use vary considerably. However, the rates of
condom use for every sexual act with a client in 1989—
46% [19] has actually dropped by 2008—33% [20] and
in 2010—38% [18].
There is even less prevalence data available for male
sex workers and for men who have sex with men. The
Poro Sapot proj ect indicated an HIV prevalence of 2.14%
[17] while Kelly et al.’s 2011 study recorded 8.8% pr eva-
lence for male sex workers and 23.7% for transgender
sex workers. The Poro Sapot project estimates that the
HIV prevalence amongst their men who have sex with
men was 4.35%, [17], whereas for Hope Worldwide cli-
ents the prevalence was 7.28%, [17].
It is extremely concerning that while there have been
large amounts of funding for HIV prevention there is no
evidence in PNG of sustained behaviour change amongst
those most at risk of HIV.
4. Discussion
Concern has been raised by a number of scholars about
the behavioural and structural impediments to HIV pre-
vention efforts to date [21-25]. In the developing world,
HIV prevention has been characterized as a “failure” by
some… Some have argued for a shift in prevention pri-
orities [26], with others [27] “unsatisfactory results” of
interventions that rely on behaviour change account for
the failure. Structural impediments to HIV prevention
include factors in the social, economic and political en-
vironments that shape and constrain individual and
community, health outcomes [28]—those largely outside
Table 1. HIV prevalence amongst female sex workers in Papua New Guinea.
Author DateDescription Place Sample size % HIV+
Bruce et al., 2010 [15] 2003A cross sectional study of re p o rted symptoms
for sexually transmissible i nfect ions among
female sex workers in PNG Port Moresby129 FSW 16.3%
Gare et al.,
2005 [16] 2003
High prevalence of sexually transmitted in-
fections among female sex workers in East
highland province of PNG: correlates & rec-
Goroka &
Kainantu 211 FSW 0%
(PoroSapot project
NCD ) 2009 Papua New Guinea, UNGASS 2008, Country
progress report NCD 675 FSW 7.4%
UNGASS 2010 (Hope
Worldwide NCD) [17] 2008/
2009 Papua New Guinea, UNGASS 2008, Country
progress report Port Moresby292 FSW 11.3%
Kelly et al. 2011 [18] 2011Askim Na Save (Ask and understand) People
who sell and exchange sex in Port M oresby Port Moresby441 FSW 19%
HIV Prevention in Papua New Guinea: Is It Working or Not?
individual control [29]. Key structural factors influencing
HIV transmission are gender inequity, poverty and mi-
gration [30]. Kippax et al. argue that changes in behav-
iour (or practice) require widespread social change. HIV
prevention efforts need to go hand in hand with parallel
efforts to promote social environments that are suppor-
tive of safer sexual behaviour [31-33], in order to provide
contexts that increase people’s power to protect their
sexual health.
Many researchers as well as those involved in policy
and program have agreed that social and structural ap-
proaches to preventing HIV become a core element. The
key drivers of HIV vulnerability that affect the ability of
individuals to protect themselves and others must be ad-
dressed in order for communities to respond effectively
to the epidemic [34]. Papua New Guinea has key social
forces that drive the epidemic. For example, Kathy
Lepani has discussed the question of mobility as a struc-
tural driver of HIV, as well as the links between gender,
sexuality and violence that are implicated in HIV trans-
mission She argues that “in Papua New Guinea, enduring
and pervasive patterns of male sexual behaviour involv-
ing coercion, violence and gang rape are highly condu-
cive to the transmission of HIV” [35].
But have these palpable issues that link widespread
social and economic change in PNG been taken up in
HIV prevention programs in PNG? And has the forms of
HIV prevention that exist in that country been successful?
Commentators on the epidemic are concerned that the
approach taken has “been largely both irrelevant and
ineffective” [13]. The IRG found in 2010 that in Papua
New Guinea ther e was “no serious HIV prevention wo rk
underway nationally or in the provinces to address the
structural drivers of the epidemic. HIV preven tion canno t
be effective and at scale unless the broader structural
determinants of the epidemic are addressed and a com-
prehensive approach is adopted ” [11].
5. Conclusion
In 2011, the Governments of Papua New Guinea and
Australia agreed to a new strategic direction for the aid
program that focuses on delivering better health (includ-
ing HIV and AIDS) and education outcomes, particularly
at sub-national level. One of the priority outcomes re-
lated to HIV agreed to at the Ministerial Forum with
PNG in 2011 was to “increase the percentage of men and
women aged 15 to 59 who had more than one sexual
partner in the past 12 months who report the use of a
condom during last intercourse from 38.9 per cent to 80
per cent by 2015, and that 80 p er cent of male and f emale
sex workers report the use of a condom with their most
recent client” [33]. In order for that to happen, HIV pre-
vention work must be intensified and must use a com-
prehensive prevention approach. Apart from Tingim Laip
HIV prevention p rograms in Papua New Guinea seem to
be a mixture of condom distribution, awareness-raising
and VCT, all important but lacking a structural approach
to the issue. They are mostly scattered, small-scale and
largely ineffective with little coordination from Provin-
cial AIDS Committees. Most evaluations argue that for
HIV prevention to be effective in PNG it needs to tackle
the major drivers of the epidemic: development, mobility
and women’s inequality.
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